, Ammar Ahmed, MD, associate professor of dermatology at Dell Medical School at the University of Texas, Austin, said at the annual Integrative Dermatology Symposium.
Data on the use of dietary supplements for vitiligo are scarce and of limited quality, but existing studies and current understanding of the pathogenesis of vitiligo have convinced Dr. Ahmed to recommend oral Ginkgo biloba, vitamin C, vitamin E, and alpha-lipoic acid – as well as vitamin D if levels are insufficient – for patients receiving phototherapy, and outside of phototherapy when patients express interest, he said.
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Melanocyte stress and subsequent autoimmune destruction appear to be “key pathways at play in vitiligo,” with melanocytes exhibiting increased susceptibility to physiologic stress, including a reduced capacity to manage exposure to reactive oxygen species. “It’s more theory than proven science, but if oxidative damage is one of the key factors [affecting] melanocytes, can we ... reverse the damage to those melanocytes with antioxidants?” he said. “I don’t know, but there’s certainly some emerging evidence that we may.”
There are no human data on the effectiveness of an antioxidant-rich diet for vitiligo, but given its theoretical basis of efficacy, it “seems reasonable to recommend,” said Dr. Ahmed. “When my patients ask me, I tell them to eat a colorful diet – with a lot of colorful fruits and vegetables.” In addition, he said, “we know that individuals with vitiligo, just as patients with psoriasis and other inflammatory disorders, appear to have a higher risk for insulin resistance and metabolic syndrome, even after accounting for confounders,” making a healthy diet all the more important.
Two case reports have described improvement with a gluten-free diet, but “that’s it,” he said. “My take is, unless stronger evidence exists, let your patients enjoy their bread.” No other specific diet has been shown to cause, exacerbate, or improve vitiligo, he noted.
Dr. Ahmed offered his views on the literature on this topic, highlighting studies that have caught his eye on antioxidants and other supplements in patients with vitiligo:
Vitamins C and E, and alpha-lipoic acid: In a randomized controlled trial of 35 patients with nonsegmental vitiligo conducted at the San Gallicano Dermatological Institute in Rome, those who received an antioxidant cocktail (alpha-lipoic acid, 100 mg; vitamin C, 100 mg; vitamin E, 40 mg; and polyunsaturated fatty acids) for 2 months before and during narrow-band ultraviolet-B (NB-UVB) therapy had significantly more repigmentation than that of patients who received NB-UVB alone. Forty-seven percent of those in the antioxidant group obtained greater than 75% repigmentation at 6 months vs. 18% in the control arm.
“This is a pretty high-quality trial. They even did in-vitro analysis showing that the antioxidant group had decreased measures of oxidative stress in the melanocytes,” Dr. Ahmed said. A handout he provided to patients receiving UVB therapy includes recommendations for vitamin C, vitamin E, and alpha-lipoic acid supplementation.
Another controlled prospective study of 130 patients with vitiligo, also conducted in Italy, utilized a different antioxidant cocktail in a tablet – Phyllanthus emblica (known as Indian gooseberry), vitamin E, and carotenoids – taken three times a day, in conjunction with standard topical therapy and phototherapy. At 6 months, a significantly higher number of patients receiving the cocktail had mild repigmentation and were less likely to have no repigmentation compared with patients who did not receive the antioxidants. “Nobody did really great, but the cocktail group did a little better,” he said. “So there’s promise.”